General Information

Does either parent have any special skill or resource to offer our club?

Emergency Information

Emergency Contact*

First NameLast Name

Phone Number*

Area CodePhone Number

Doctor*

First NameLast Name

Phone Number*

Area CodePhone Number

Allergies and/or other known conditions we should be aware of

Permissions

If parents can not be reached and emergency medical advice is needed, permission is granted to phone my child's doctor. In case of medical emergency requiring immediate emergency care, I authorize transportation to nearest medical facility*

I Agree

I, the legal parent/guardian, authorize you and your agents to involve our child in these various trips and activities, direct you to rely upon the registration forms previously tendered for emergency contact persons for the benefit of our child, authorize the administration of any medicines deemed necessary by emergency health professionals in the event of non-availability of parent/guardian, acknowledge that all known allergies or other conditions impacting the health and well being of our child are listed below, and further release the Chabad and its agents from liability arising during the course of these various field trips and activities*

I Agree

I/we understand that my/our child(ren) may be included in photographs and video footage that may be photographed or filmed during CTeen. I authorize CTeen and Chabad of Wilmette to use these photos/videos to promote its programs and services in print, web, and other promotional contexts*